Maisonneuve Fractures

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The ankle is the most commonly injured joint in the body. Due to this sports medicine professionals can often suffer from “tunnel vision,” confusing a “simple ankle sprain” for a more complex issue. The Maisonneuve Fracture is one such injury.

Ankle injuries are classified into four injury patterns. The injury pattern determines how the force is borne on the ankle joint and consequently which structures are injured. They are:

  • Supination-Adduction (SA)

  • Supination-External Rotation (SE)

  • Pronation-Abduction (PA)

  • Pronation-External Rotation (PE)

Supination-Adduction Stress

With an SA mechanism, the foot is supinated, or inverted, causing an adduction force on the talus. The inversion stress can result in:

  1. Injury to the calcaneofibular ligament.

  2. Transverse fracture of the lateral malleolus.

  3. A secondary force, causing talur adduction, can cause impaction of the talus on the medial malleolus, resulting in an oblique fracture.

Supination-External Rotation Stress

This is the most common ankle injury mechanism. The foot is supinated and an external rotation force results on the talus. This can result in up to four sequential injuries.

  1. Anterior Inferior Tibiofibular ligament injury.

  2. A short oblique fracture of the fibula.

  3. A fracture of the posterior malleolus

  4. A transverse fracture of the medial malleolus or a tear of the deltoid ligament.

Pronation-Abduction Stress

This  injury mechanism results in a pronated foot with an abducting force exerted on the talus. This can result in up to three sequential injuries.

  1. A transverse fracture of the medial malleolus caused by a tense deltoid ligament.

  2. The abducting talus stresses the tibiofibular syndesmosis, resulting in a tear of the anterior tibiofibular ligament.

  3. Continued abduction of the talus results in an oblique fracture of the distal fibula.

Pronation-External Rotation Stress

This injury mechanism results in a pronated, or everted, foot with external rotation forces acting through the talus. Possible sequential injuries are:

  1. A medial malleolar fracture

  2. A syndesmosis injury.

  3. A short spiral fracture of the fibula, due to the external rotation force, usually 6 to 8 cm above the syndesmosis, but can be as high as midshaft.

  4. A fracture of the posterior malleolus.

The common mechanisms of injury listed above can not account for the multitude of injuries associated with a Maisonneuve fracture. The exact mechanism of the fracture is not well understood. Due to the nature of the injury, a multi directional force must occur at the ankle.

The fracture is characterized by:

  • A tear of the anterior tibiofibular ligament.

  • A fracture of the posterior malleolus.

  • An anteromedial capsule sprain.

  • A fracture of the proximal fibular neck.

  • A fracture of the medial malleolus or deltoid ligament tear.

Therefore, the evaluating clinician must rely on a highly detailed history and physical examination. Simply concentrating on the physical examination of the ankle area will result in missed clinical findings.

The radiographs show the typical Maisonneuve fracture characteristics. X-ray “a” shows a widening of the syndesmosis (arrow on right) indicating a tibiofibular ligament sprain. The left arrow points to a small medial malleolar fracture with possible deltoid ligament disruption. X-ray “b” shows a more proximal fracture of the fibula. The proximal fibula fracture can be easily missed if radiographs are ordered for the ankle only. When a medial malleolar fracture or syndesmotic disruption is suspected, the treating physician should order radiographs of the entire lower leg.

Another example of a Maisonneuve fracture can be seen in this radiographs on the second row. The fibular fracture is near the proximal tibiofibular joint. This was accompanied by a medial malleolar fracture.

Treatment

These types of fractures result in a open reduction with internal fixation (ORIF). The orthopaedic surgeon will reduce the fracture anatomically and use plates and screws to fix the reduction. The fluoroscopic picture at the bottom of the page shows the result of an ORIF of a medial malleolar and tibial shaft fractures and a syndesmosis disruption. The horizontal screw holding the tibia and fibula together will allow the syndesmosis to heal.

The syndesmosis screw will have to be removed in a subsequent surgery. If not removed, the screw’s presence will not allow for normal ankle motion and could break causing more pain.

Rehabilitation should proceed as directed by the physician to restore normal strength, range of motion, and proprioception.

 

 

 

 

©2000 - 2006 David Edell

Information on this site is not a substitute for physician directed care.

Please consult your personal physician for more detailed information

concerning specific injuries or illnesses.

Last Update for AthleticAdvisor.com: 06/04/2006 12:01:52 PM